get active feel good! - paul...

Get ActiveFeel Good!

Paul Farrand, Adrian Taylor, Colin Greaves & Claire Pentecost

Mark’s case study

BAcPAc_Mark_BAcPAc Case Study_Mark 01/03/2013 16:23

Contents


Mark is a thirty nine year old father of two with three main loves in his life. He loves Emmahis wife and sons Aaron and Max, his work as a carpenter and his dog Barney. The past fewyears were very good and recently Mark secured a loan to buy new premises for hissuccessful carpentry business. Whilst he loved the new set up at work, it meant longer hoursat work which resulted in him spending less time at home with his family.

About a year ago, Mark’s world was turned upside down when Emma became unwell withbreast cancer. He was very worried about Emma and started to feel guilty as he had to spenda lot of time at work and not at home where he felt he should be. Although Emmarecovered, Mark’s mood had become very low, he was having difficulty sleeping and was noteating well. He was also no longer doing the things he used to love, such as dropping Aaronoff at school, tinkering around with his motorcycle or walking Barney. At first Emma put thisdown to the shock of her illness. But with no improvement in his mood Emma finallymanaged to convince Mark to see his GP.

Mark’s story is about someone whoused behavioural activation to helpimprove his low mood. Once his moodbegan to lift he was encouraged togradually increase his physical activity.

MARK’S STORY

1


MARK’S FIRST APPOINTMENT

Following an assessment with Sally, a Psychological WellbeingPractitioner (PWP), Mark was identified as having depression.

Sally explained what depression was and then identified how it was linked to Mark’sfeelings of tiredness, thoughts that he had ‘Let Emma down’ and could explain why he hadgiven up a lot of the things he used to enjoy. Sally also listened to the way in which Mark’sdifficulties were impacting on his life, and working together they identified some thingsMark wanted to get out of treatment.

Sally then introduced something called Behavioural Activation and explained that researchhas shown it to work well for depression and was recommended by the NHS. She said it putstructure back into people's lives by helping them to gradually build up their everydayactivities and supporting them to become more physically active. Mark really liked the ideaof getting physically active again so Sally gave him a self-help programme called ‘Get Active;Feel Good!’. She explained how it would take him through behavioural activation. Her jobwas to support him working through the programme at his speed. Sally then set up a timeto see him and requested that he complete a ‘My Starting Point Diary’ over the course ofthe next week. This would help them both see how much activity he was currently doing.

2


Today’s Date

Item 1

I can do this now (circle a number):

0 1 2 3 4 5 6

Not at all Occasionally Often Anytime

Today’s Date

Item 2


0 1 2 3 4 5 6


What Do You Want to Get Out of Treatment?

The first thing to think about was identifying some things Mark wanted out of treatment.

5th March

Walk Aaron to school every day.

O

5th March

To take Barney out on longer walks most days again

O

3


SESSION 2

During the next session Mark and Sally reviewed his ‘My Starting Point Diary’.

Mark’s Starting Point Diary

Monday Tuesday Wednesday T

Co

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ents

Eve

nin

g

Aft

ern

oo

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M

orn

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What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

Work

Work

Work

Work

Watched Television

Went to bed early

Felt tired

Work

Work

Work

Work

Fell Asleep

Went to bed early

Did not want to do

anything after work

In bed feeling

drained

In bed feeling

drained

In bed feeling

drained

In bed feeling

drained

Had a bath

Watched television

Did not go to work

as too tired, slept

a lot

4


Thursday Friday Saturday Sunday

Work

Work

Work

Work

Took Barney out

Had a bath

Relaxed after

taking Barney out,

A bit better today

Work

Work

Work

Work

Got takeaway

Watched television

Struggled today,

looking forward to

weekend

Watched television

Walked to shop

Fell asleep

Watched television

Had a bath

Watched television

A disappointing day,

felt tired and no

energy

Took Barney out

Tried to read

newspaper

Helped make lunch

Fell asleep

Watched television

Went to bed early

Nice to get out

with Barney, but

flagged later in the

day

Mark was alarmed to see how his week mostly consisted of working, watching television andsleeping, and contained very little physical activity. He was also shocked to see that whilst Emma wasdoing things with the boys at the weekend, he was sleeping or doing very little on his own. This madehim feel very sad. However it also helped him realise that he really needed to do something to sorthimself out. He felt a bit better when Sally said that the way he felt was perfectly normal, and thatwith his hard work and her support for Behavioural Activation they could get on top of his depression.

5


WORKSHEET A

Mark knew a little about Behavioural Activation already as he hadread the bit about it in ‘Get Active; Feel Good!’, but was pleased to gothrough it again.

Sally started by explaining how most people’s lives are made up of three types of activitiescalled routine, pleasurable and necessary. She then helped Mark to identify a few of eachand write these in Worksheet A.

He was soon able to identify a few activities in each area and Sally suggested that hecomplete the list at home before the next session. Mark was happy to do this but wasconcerned that some of the activities would be too hard. But Sally helped him to grade themin terms of how difficult they were.

Routinee.g. cooking, walking the dog,food shopping

Pleasurablee.g. going out with friends,reading

Necessarye.g. paying bills, walkingchildren to nursery

Cooking proper meals!

Shave

Taking Aaron to

school

Restore my motorbike

Going out with Emma

Taking boys to

‘Pleasureland’

Taking Barney for a walk

Pay work invoices

Get car tax paid

Mark’s Worksheet A : Identifying activities

Under each type of activity write down what you want to be able to achieve.

6


WORKSHEET B

Mark was asked to write down all the activities identified inWorksheet A, or any new ones he thought of, in terms of howdifficult he would find them to do on Worksheet B.

Initially Mark struggled as he found all activities very difficult and put them all in ‘The MostDifficult’ section. However, with some support from Sally he remembered some advice in‘Get Active; Feel Good!’ about breaking tasks down into easier ones. Using this advice hewas able to break the task ‘Take Aaron to school every day’ to ‘Take Aaron to school on twodays a week’ which he felt was far more possible. Using this method Mark was soon able toorganise his activities from least to most difficult.

Once Mark knew what he was doing he was encouraged to complete Worksheet B on hisown, as Sally was keen to use the remainder of the session help Mark begin to put the‘Least Difficult’ activities into Mark’s ‘Next Steps Diary’.

Least difficult Medium difficult Most difficult

Mark’s Worksheet B : Listing activities according to their difficulty

Shave every day

Take Aaron to school two

days

Take Barney on a

10 minute walk to the park

Order parts for the

motorbike

Cooking

Take boys to ‘Pleasureland’

Take Aaron to school

Pay work invoices

Go for a meal with Emma

7


Mark’s Week 1 Next Steps Diary


Co

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What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

Walk Aaron to

school 8.20-8.30

Work

Work

Work

Felt very tired all

morning

Shave

7.45

Work

Work

Work

Felt good to feel

clean and smart

today

Shave

7.45

Work

Work

Work

Glad nothing

planned for today

W

s

8

W

W

T

5

N

m

E

e

Sally then worked with Mark to begin to put some of the activities from the ‘Least Difficult’ sectionof Worksheet B into the ‘Next Steps’ diary. She stressed it was important that Mark spread theseactivities across the entire week, that they felt manageable, and could be done at a specific time.Sally was however worried that Mark had written down ‘pay work invoices’ in the ‘Most Difficult’section but this was not added to the diary. She asked Mark what the consequences of not payingthe invoices could be. He admitted that if he did not pay them soon it could be quite serious.

8



Walk Aaron to

school

8.20-8.30

Work

Work

Take dog out

5.30-5.45

Not as tired this

morning.

Exhausted this

evening

Shave

7.45

Work

Work

Work

Glad nothing

planned for today

Small food shop

with Emma

9.30-10.15

Cook a simple meal

1.30-2

Glad to get out of

house this morning.

Felt exhausted

after dinner

Shave

9am

Tinker with

motorbike

2-2.30

Pay work invoices

6pm

Once I got going

felt better. Great

to sort work

invoices and work

on the motorbike

Equally however he felt that this activity was just too difficult to manage. Sally therefore helpedMark problem solve ways he may be able to get these invoices paid, and it was decided that sharingthis difficulty with Emma may help. Once Mark understood how to put activities into the diary hewas encouraged to give it a go and see what he could manage over the next week. At the end ofeach day Sally also suggested that he write any comments he may have in the diary. These wouldbe useful to discuss at their next session.

9




Co

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ents

Eve

nin

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What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

Walk Aaron to

school 8.40-8.50

Work

Work

Work

Tinker with the bike

Read to the boys

6-6.15

Really enjoyed

reading to the boys

Walk Aaron to

school 8.40-8.50

Work

Work

Work

Cook dinner

5-5.45

Really wanted to

rest when I got

home but forced

myself to cook

dinner

Work

Work

Work

Walk dog 6-6.15

Read to the boys

6.45-7

A little tired today

but enjoyed time

with the boys

W

s

W

W

W

W

F

a

m

w

a

AS THE WEEKS PASSED

With Sally’s help Mark continued to increase his activities. Togetherthey reviewed progress made during the previous week.

10



Walk Aaron to

school 8.40-8.50

Work

Work

Work

Walk dog 6-6.15

Felt really good today

and noticed that my

mood lifts when out

with Barney especially

at the park

Work

Work

Work

Walk dog 6-6.15

An OK day

Shopping for 3 days

groceries 10-11.30

Cinema with Emma

7.30-9.30

Down but better in

the evening. Feel

more tired if activity

is less enjoyable

Family walk with

the dog 10-11

Read the paper

1-1.30

Tinker with the

bike 3-4

Read to the boys

5.30-6

Mostly a good day,

really felt like I got

a lot done today

11


When good progress had been made, they continued to schedule in new activities fromWorksheet B into the ‘Next Steps’ diary to use the following week. It was not always easygoing however. During his fourth week of treatment Mark found it really difficult to completethe activities he had set himself and became so upset that he gave up altogether. However, hedid attend the next session and was glad that Sally was pleased to see him.

Together they reviewed the ‘Next Steps’ diary to identify what had gone wrong. With Sally’shelp, Mark was soon able to identify that, as the previous two weeks were so successful, hehad got a little carried away and added too many activities for that week. To make mattersworse he added them just to the first two days following the session! Although having asetback, Mark now felt he had a much better idea as to how to proceed.

Since then things had gone really well. When looking back over his previous ‘Next Steps’diaries, Mark realised how much more he was now doing and how his life was looking almostnormal again.

MOVING ON WITH PHYSICAL ACTIVITY

During the sixth support session Mark discussed feeling really proudwith his progress. He was spending more time with his family, and wasreally pleased to have started working on his motorbike again; even ifit was still in bits in the garage!

Mark also highlighted how he felt better in himself. He was beginning to find his old energyagain, was eating better, was more focussed at work and was having fewer guilty thoughtsabout Emma and her cancer. Scores on the questionnaires filled out every week with Sally alsoindicated his low mood was beginning to lift.

Mark was really pleased with his progress and was interested when Sally talked again aboutincreasing physical activity. Looking over his previous diaries they both noticed how much heseemed to be enjoying the activities that required him to be physically active. They also noticedthat many of these activities were outdoors. In particular it was clear that Mark really enjoyedtaking Barney for a walk which he now managed most days, although even now he still felt alittle tired afterwards. Sally and Mark also discussed the wider health benefits of beingphysically active. Mark was keen on this as over the past 12 months his physical health hadgot a lot worse and he had put on weight.

However, Mark was also aware that he had not done a lot of physical activity since playingfootball in his twenties. Whilst wanting to get fitter, equally he did not feel exercising wasright for him at the moment. Sally, however, soon put Mark at ease. She discussed how beingmore physically active did not have to mean doing more exercise. It could simply meanfocussing more upon the things he was already doing that included movement and trying tobuild these up.

To help Mark think about different types of physical activity Sally introduced him to WorksheetC. Sally stressed that as well as the activity involving movement it was equally important thatMark only chooses physical activities that he would enjoy, and where possible could build upover time if he wanted to. After some discussion Mark was able to identify several physicalactivities, some from looking back over his dairy and some new ones. He wrote these down inWorksheet C. Mark and Sally then identified any problems that may arise when trying to dothe physical activities and also tried to identify potential solutions.

12


Proposed physicalactivity

Difficulties doingphysical activity

Ways to overcomedifficulties

Worksheet C : Thinking about physical activity

Mark thought about activities that he might like to do by thinking about what he might

enjoy and what was realistic to fit into his normal week

Looking at the options listed on Worksheet C, Mark decided to increase walking Aaron to

school to every morning as he enjoyed this time but that the best physical activity to focus

on was ‘Walking further and more often with Barney’.

Walking further and more

often with Barney

Jogging

Getting involved with

football training at Aaron’s

School

Walk Aaron to school

Possibly get tired, and

may not feel like it after

work

Not done anything like this,

seems too big a step at

the moment

May take time to organise,

have not played for so

long my skills will be rusty

and I feel out of shape.

May be difficult to

commit

Actually doing this more

often now, but mornings

so hectic that increasing

may be hard to do

Will need to make sure I

finish work on time and

remember that when out I

feel I have more energy

Perhaps after I have

started doing more

walking, but a long way

off?

Great idea but not ready

for this just yet, perhaps

a longer term goal

Getting both Aaron and

me ready the night

before and getting up

earlier

13


WORKSHEET D

Sally then introduced Mark to Worksheet D and discussed the need tomake an explicit plan for each physical activity.

Then after doing the activity to record how long he did it for, and any comments he may

have. Sally also introduced Mark to the idea of using a pedometer. Although he had never

actually used one he had read about it in ‘Get Active, Feel Good!’ and was interested. They

discussed how it would be great to use it to record the number of steps he took each day.

Mark really liked this idea and was keen to see just how much he was doing.

14


My physical activity goals for the week are:

1. Take Barney for a 20 min walk to the park on Monday, Wednesday and Friday after

work and 60 min at the weekend

2. Walk Aaron to school everyday

3.

Time and/or steps taken

CommentsActivity 1, 2 or 3

Date

Total number of stepsthis week

Worksheet D : Setting and tracking physical activity goals

Was a bit rushed today, but did both

I found I enjoyed the air. Felt good when I got

to work

Rained hard today, so not as enjoyable, but felt

refreshed, although did not do the full 20

minute walk with Barney

Walked to the park quicker, and had time for a

quick game of ‘fetch’

Great time, wonderful day and loved time with

Emma on our walk

Struggled a little but made it and got easier

10 mins

20 mins

4345 steps

10 mins

2303 steps

10 mins

15 mins

4245 steps

10 mins

2313 steps

10 mins

20 mins

4543 steps

60 mins

5744 steps

60 mins

5842

29335

2

1

2

2

1

2

2

1

1

1

14th May

15th May

16th May

17th May

18th May

19th May

20th May

15


OVER THE NEXT FEW WEEKS

With Sally’s support, Mark continued to increase his physical activity.Everyday he managed to walk Aaron to school before work and wasstill taking Barney on walks to the park after work.

Reading ‘Get Active, Feel Good!’ Mark was also able to increase his physical activity using

F.I.T.T. After speaking to Emma at home he realised that increasing the amount of time he

took Barney out would be really difficult if he was to carry on spending time with the boys.

So he decided to carry on walking for the same amount of time as before but to increase the

intensity of the walk. This he did by walking a different way to the park on a route that had a

steep hill. More generally however he also noticed that he was also walking more with Emma

and the boys. This was clear from his pedometer readings recorded in Worksheet E that had

increased week on week and he noticed he was less breathless walking up the hill too.

16


Worksheet D : Keeping track of your activity by measuring stepseach week

Week 1 2 3 4 5 6 7 8 9 10

Tota

l nu

mb

er o

f st

eps

each

wee

k

70,000

65000

60000

55000

50000

45000

40000

35000

30000

25000

20000

15000

10000

5000

1000

0

x

xx

17


MARK’S WEEK 7 NEXT STEPS DIARY

Sally continued to support Mark with his ‘Next Steps’ diary to

increase his other routine, necessary and pleasurable activities.



Co

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What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

What

Where

Who

Walk Aaron to

school 8.40-8.50

Work

Work

Work

Walk Barney to

park 6-6.20

Read to the boys

6.45-7

Enjoyed walking Aaron

to school, tired this

evening. I really

pushed on the walk

with Barney

Walk Aaron to

school 8.40-8.50

Work

Work

Work

Read to the boys

6.45-7

A bit low this

afternoon but nice

to read to the boys

Walk Aaron to

school 8.40-8.50

Work

Work

Work

Walk Barney to

park 6-6.20

Nice to spend time

relaxing with Emma

W

s

W

W

M

F

t

18


Looking back over his diary felt really good. He noted that during the last week he hadcompleted some of the activities that at the beginning of treatment were at the top of hisdifficulty sheet. From his ‘Next Steps’ diary he was able to identify that he was now doingmuch more with the boys and Emma. He was even managing to get those difficult necessaryactivities completed, such as getting the car tax paid.


Walk Aaron to

school 8.40-8.50

Work

Work

Meal with Emma

Felt really good

today, got loads done

Walk Aaron to

school 8.40-8.50

Work

Work

Work

Walk Barney to

park 6-6.20

A good day,

Starting to feel I

am getting back

into a good routine

Take boys to park

9-10

Shopping for week

10.30-12

Pay road tax for

car 2pm

Read to the boys

5.30-6

Good day got a lot

done. Starting to

feel like a good

husband again

Working on

motorbike 10-11.30

Family walk 4-4.30

Lovely time on the

beach feel ‘normal

again

19


PREPARING FOR THE END OF TREATMENT

Mark reported feeling much more like normal now. He felt much lesstired and had more energy than he had for a long time.

This was also noted by his workmate, who commented how he was much more ‘chatty andenthusiastic’ at work. His appetite had also returned and he really enjoyed going out for ameal with Emma. He could even enjoy having a pudding now he had lost some weight.Although still feeling worried about the possibility of Emma’s cancer returning, he no longerfelt any guilt. Given these improvements Sally suggested to Mark that as long as things werestill fine next week it may be that his regular sessions could end.

Preparing for the end of treatmentAll was well during the next session. Mark reported increasing his physical activity evenfurther and feeling ‘back to normal’. Reviewing what he wanted out of treatment it wasclear that he was now doing the things he wanted to do. It was agreed that his weeklysessions with Sally would now end.

20


What Do You Want to Get Out of Treatment?

Mark was now able to achieve the things he wanted out of treatment.

Today’s Date

Item 1


0 1 2 3 4 5 6


Today’s Date

Item 2


0 1 2 3 4 5 6


4th July

Walk Aaron to school every day

O

4th July

To take Barney out on longer walks most days again

O

21


LOW MOOD ALARM AND ACTIVITY TOOLKIT

Sally discussed ways for Mark to try and stay well and together theywent through Step 9 of ‘Get Active, Feel Good!’.

Mark found it really helpful creating his own personal ‘low mood alarm and activity toolkit’and thinking about the activities that helped him.

Sally also discussed how it was perfectly normal to feel down occasionally. However if Markstarted to feel the way he had written in his ‘Low Mood Alarm’ for a while and this started toimpact on his life again then it could be best to think once again about the things thathelped. Sally also indicated how going back through ‘Get Active, Feel Good!’ could be useful.

ONE MONTH LATER

One month later as planned, Sally phoned Mark to check on hisprogress and see how he was getting along with his physical activity.

All seemed to be well. He was spending far more time with Emma and the boys and Barneyhad not walked so much in his life! Mark did say however that he still found some days werebetter than others. However once he was walking outside with Barney or Emma and theboys things seemed better.

22


My low mood alarm and activity toolkit

Last time I was depressed I did thefollowing things differently or stopped

doing them altogether...

Last time I was depressed thefollowing unhelpful thoughts ran

through my head...

Last time I was depressed I felt thefollowing physical symptoms...

Last time I was depressed, doing thefollowing activities really helped...

Took time off work, stopped doing

things with the boys, did little around

the house, shaved and washed less

frequently, more time in the house

doing nothing

"I should have spent more time with

Emma", "I am a waste of space", "I am

a bad dad"

Very tired, slow, put on weight,

irritable, problems sleeping

Walking Barney, going to the park

with the boys, shaving!, spending time

with Emma, tinkering with my bike

23


Dr Paul Farrand is a Senior Lecturer within the Mood Disorders

Centre and Director of Psychological Wellbeing Practitioner training

within Clinical Education, Development and Research (CEDAR) at

the University of Exeter. His main clinical and research interests are

in the area of low intensity cognitive behavioural therapy (CBT),

especially in a self-help format. Based upon his research and clinical

practice he has developed a wide range of written self-help

treatments for depression and anxiety.

Professor Adrian Taylor specialises in developing and

evaluating interventions and support for health behaviour change

as a way of improving and regulating psychological well-being. As

one of the Directors of Research in the College of Life and

Environmental Sciences at the University of Exeter, he has led and

supported many nationally and internationally renowned research

studies. His work has featured in a variety of clinical guidelines for

helping people to gain control over various health behaviours as

well as mood.

Dr Colin Greaves is a health psychologist and Senior Research

Fellow at the University of Exeter Medical School. He has research

expertise in developing and testing interventions to help people

undertake lifestyle change. Based upon his research he has

developed an intervention to help people with asthma manage

their condition, several weight loss interventions and a self-help

manual for people with heart failure.

Dr Claire Pentecost is a Research Associate at the Mood

Disorders Centre, University of Exeter. Her research experience is in

designing and delivering programmes for lifestyle change for

people with diabetes, depression and other long-term conditions.

Claire’s most recent research looked at the reasons why some

people do, and some people do not take up lifestyle change

courses recommended by a GP.

ABOUT THE AUTHORS

24


This trial is funded by the National Prevention Research Initiative (NPRI-4) comprising

of the Medical Research Council and Partners:

Alzheimer’s Research Trust

Alzheimer’s Society

Biotechnology and Biological Sciences Research Council

British Heart Foundation

Cancer Research UK

Chief Scientist Office, Scottish Government Health Directorate

Department of Health

Diabetes UK

Economic and Social Research Council

Engineering and Physical Sciences Research Council

Health and Social Care Research Division, Public Health Agency, Northern Ireland

Medical Research Council

Stroke Association

Wellcome Trust

Welsh Government

World Cancer Research Fund

Acknowledgement:

This booklet is based on the behavioural activation model included within ‘Reach Out:

National Programme Educator Materials to Support the Delivery of Training for Psychological

Wellbeing Practitioners Delivering Low Intensity Interventions’ by Professor David Richards

and Dr Mark Whyte.

Copyright statement:

© 2013. The right of Paul Farrand, Adrian Taylor, Colin Greaves and Claire Pentecost to be

identified as the authors of this work has been asserted by them in accordance with the

Copyright, Designs and Patent Act, 1998. All rights reserved. The booklet has been produced

on the condition that it shall not, by way of trade or otherwise, be lent, sold, hired out or

otherwise circulated in any form binding or cover other than that in which it is published and

without a similar condition including this condition being imposed on the subsequent reader.

Materials in this work may not be freely copied for any purpose.

Research Statement:

This booklet has been developed as part of a research grant awarded by the National

Prevention Research Initiative http://www.mrc.ac.uk/NPRI/


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